What are these hormones anyway?

Since I’ve been reading and writing about menopause and hormone replacement for a couple of years now, I tend to get ahead of myself.

I assume everyone else has been elbows-deep in it, too. But perhaps we should take a step back and look at the basics for normal people who haven’t made this a part of their entire identity.

Most of us instinctively know that the changes we’re feeling are because of hormones.

But what hormones are we talking about exactly? What roles do they play? And more importantly, when you’re trying to troubleshoot or get help, what lab tests should you be asking for?

Let’s start at the beginning…

What’s a hormone?

Hormones are chemical messengers that tell your body what to do and when. They’re produced in your glands (ovaries, thyroid, adrenal glands and pancreas), and travel through your bloodstream, giving instructions to other body systems.

When most people hear “hormones,” they typically think of so-called “sex” hormones—estrogen for women and testosterone for men. But that’s only scratching the surface.

• Insulin is a hormone—it tells your body how to regulate blood sugar.
• Thyroid hormones control your metabolism.
• Vitamin D is also a hormone, which influences bone health and immune function.

The fact that we don’t even think twice about replacing any of these hormones if we’re deficient, yet replacing our “sex” hormones is somehow controversial, is PREPOSTEROUS.

We would never tell a diabetic, “It’s fine! Your body will adapt!” or “Maybe you should try yoga. It’ll help you relax.”

But I digress…

When it comes to perimenopause and menopause, there are typically 5 primary hormones at play (although dysregulation in these can affect the ones above…but that’s a topic for another day).

Testosterone (T)

You might think it’s odd that I put testosterone first in a conversation about women and menopause, but there’s a good reason.

Most of us were taught that estrogen (E) is the female sex hormone and testosterone is the male sex hormone. But the truth is, women have more circulating testosterone in their bodies than estrogen during our prime reproductive years. I KNOW! I had no idea either. But it’s true!

The reason most of us (including doctors) think that women have more E than T is because they’re measured in different units in lab results.

Typical lab results for estrogen (aka estradiol) are measured in pg/mL (picograms per milliliter).

Typical lab results for testosterone are in ng/dL (nanograms per deciliter)—which is basically 10X pg/mL.

1 ng/dL = 10 pg/mL

So if your labs show an estradiol level of 30 pg/mL and testosterone level of 30 ng/dL, it means your testosterone is actually 10X the level of your estradiol.

Put another way: a testosterone level of 30 ng/dL = 300 pg/mL – 10X higher than estradiol.

T is produced in both the ovaries and adrenal glands (albeit in a smaller amount) and plays a crucial role in:

• Muscle and strength, helping you to stay fit and avoid frailty
• Bone density, supporting healthy bone structure
• Energy, giving us motivation, drive and zest for life.
• Focus, supporting concentration, cognition and decision making
• Mood, helping us to feel engaged, confident and reducing anxiety
• Libido and sexual response, both desire and arousal.

T is the hormone that helps you feel strong, sharp and confident. It gives you “get-up-and-go.”

And when it declines as we age (starting as early as our 30s), that’s when we notice our get-up-and-go has got up and left! We feel tired, unmotivated, lazy and depressed. And sex drive? Never heard of her.

Estrogen (E)

Estrogen plays a crucial role in so many body systems: your brain, bones, skin, heart and mood. It influences your metabolism, supports collagen production for healthy skin and joints and maintains vaginal and urinary health. It even helps regulate body temperature and sleep.

That’s why when E levels dip, we FEEL IT across our entire bodies.

• Hot flashes and night sweats as our temperature regulation goes haywire.
• Mood swings and brain fog – the brain is loaded with estrogen receptors and when they’re starved for E, it doesn’t function well.
• Dry, itchy and thinning skin. It feels like the Sahara all over, your skin takes on that “crepey” look and you might show more bruising than before. Even your ears get super itchy!
• Vaginal dryness and urinary incontinence. Just like the skin on the rest of your body, the skin “down there” becomes dry, itchy and thin, causing painful sex, increased risk of urinary tract, yeast and bacterial vaginosis infections, plus urge incontinence—when you gotta go, you gotta go RIGHT NOW.
• Weight gain, especially in the midsection. There are actually two mechanisms of action here: your metabolism changes because low E affects how our body uses insulin, but also remember that testosterone our ovaries make? When they’re failing and can’t convert the T to E as well, the body needs fat cells to do all that heavy lifting, so it packs on more fat. Good times!
• Heart palpitations – again, there are tons of estrogen receptors in the heart, and when it’s depleted, it causes electrical signals in the heart to misfire, creating arrhythmias and palpitations.

Progesterone (P)

When we’re younger and still cycling, progesterone is produced in greater amounts after ovulation as our body prepares for possible pregnancy. For most, it has calming, anti-anxiety effects and promotes sleep (higher P is one reason you feel so lazy during PMS). P also skyrockets in pregnancy, in part to stabilize the uterine lining to support a fetus.

When P drops in perimenopause, it causes us to feel more anxious, irritable, have trouble sleeping and get that wired-but-tired feeling. And it’s why many of us suffer from abnormally heavy periods. There’s not enough P to stabilize the lining in the uterus, so it sheds…and sheds…and sheds.

Follicle Stimulating Hormone (FSH)

FSH is produced by the brain in the pituitary gland. When we’re still cycling, FSH signals the ovaries to grow and mature an egg each month. As we run out of eggs and estrogen production slows during perimenopause and menopause, the brain tries to “shout louder,” increasing FSH production in an attempt to get the ovaries to respond.

That’s why high FSH levels are one of the lab markers doctors use to confirm menopause—it means the brain is sending the message, but the ovaries aren’t answering.

Luteinizing Hormone (LH)

LH is another messenger hormone from the brain that triggers ovulation—the release of an egg—and signals the ovary to start making progesterone. During reproductive years, LH and FSH work in harmony to regulate the menstrual cycle.

After menopause, when ovulation stops, LH levels stay elevated because the signal keeps firing, even though the ovaries are no longer responding.

I know it’s a lot. But don’t stress.

As you can see, menopause is about far more than declining estrogen. It’s so much more than just hot flashes and night sweats. These aren’t just “sex” hormones.

These hormones impact literally every aspect of our body—from energy and mood to metabolism and sleep to muscle strength and even our digestion.

There’s a complex interplay at work, but I don’t want that to feel intimidating. You don’t have to become an expert in all of this to get help.

But knowledge is power and understanding how your body works can help you find a provider who will at least look at the entire picture, not just estrogen. One who recognizes the role that each of these hormones plays in our overall health and well-being.

I’ll do a deeper dive on lab work in a future post. But wanted to get these basics out of the way first. And I’ve already gone on too long!

**This is not medical advice, and I am not a doctor. The information here is based on my personal experience and research.

Let’s get this out of the way up front.

Any time the subject of hormone replacement comes up, inevitably someone will say:

“I’ve heard hormone replacement causes breast cancer.”

“My doctor says HRT isn’t safe because it causes blood clots.”

Does it, though? Let’s look at the data.

The claim that HRT is dangerous comes from the results of the Women’s Health Initiative, announced in 2002. Before that, HRT was extremely popular and routinely prescribed for women, with nearly 40% of women ages 52-65 using HRT.

But the WHI led to widespread panic, and doctors abruptly stopped prescribing it. Use of HRT dropped to less than 5% in the years following.

By many accounts, this has had immense negative consequences for women’s health and quality of life. Well-known longevity expert Dr. Peter Attia has called the WHI “one of the biggest failures of modern medicine.”

The WHI study was flawed from the start:

• The women in the treatment group were at high risk for disease already. Women in the WHI study were not randomized into the treatment vs. placebo groups based on their baseline cancer risk. In fact, it turned out that those in the treatment group (who got hormones, not placebo) had higher lifestyle risk factors. They had disproportionately more pre-existing conditions, including high blood pressure, obesity and smoking history, than the women in the placebo group.

  In other words, one could argue that any conditions those in the treatment group developed likely would have developed anyway, regardless of whether they took hormones.

• The women were older. The majority of women were over age 60, with an average age of 63—much older than the average age of menopause. This also naturally predisposed participants to a higher risk of cancer, heart disease, etc. simply by virtue of their age.

  The age range was 50-79, which means there was very, very little (if any) data collected on starting HRT in perimenopause (38-50 years old) before any of those disease conditions developed. There is now, and all evidence points to the earlier you start, the better.

• The hormones used are not what’s used today. The WHI used conjugated equine estrogens (from pregnant horse urine) in combination with medroxyprogesterone acetate. These are synthetic, non-bioidentical hormones—not the natural estradiol and progesterone produced by humans–and medroxyprogesterone acetate is virtually obsolete now.

  Modern bioidentical HRT (called BHRT) uses estradiol and micronized progesterone. (Or at least it should. This is what you want to request from your doctor.)

  What does all of this mean? Doctors who say HRT is unsafe base their dire risk warnings on DIFFERENT medications than what they should be prescribing. They’re comparing apples to oranges. (FWIW, oral birth control is fully synthetic and DOES carry increased risk of blood clots—albeit small—yet doctors prescribe it like candy to literal children and many stay on it for most of their lives. Not to mention, BHRT is a MUCH lower dose than birth control. Make it make sense!)

• The media blew the risks of breast cancer completely out of proportion (shocker, I know), reporting a 24% increase in breast cancer from hormones. But what they didn’t explain was that this is RELATIVE risk, not ABSOLUTE risk.

  What does this mean? The actual increase in cases was very small—roughly 5 out of every 1,000 women in the HRT group developed breast cancer, versus 4 out of every 1,000 who received no hormones.

  I mean, COME ON. This is FAR lower than the risks associated with smoking or obesity and not even close to the risks of breast cancer from alcohol (that’s a story for another day). But 1/1,000 case increase doesn’t make for an exciting headline, now does it?

In fact, the group who received estrogen-only actually saw a REDUCED risk of breast cancer and cardiovascular diseases. In other words, estrogen does NOT cause cancer.

If it did, wouldn’t the rate of breast cancer be higher in young or pregnant women when estrogen is at its highest?

MOST telling: There has not been a decline in breast cancer since the WHI claims were announced, despite a dramatic drop in the number of women treated with HRT. In fact, breast cancer rates have increased in the U.S. by about .5% annually. And cardiovascular disease continues to be the leading cause of death in women.

You know what else has increased, MASSIVELY? Prescriptions for antidepressants, anti-anxiety, overactive bladder, anti-inflammatory and sleep medications and even epilepsy drugs like gabapentin to treat the symptoms of menopause.

Plus, new drugs like Veozah for hot flashes and Vyleesi for low sexual desire have come on the market.

But none of these treat the underlying issue—hormonal decline—and many of these come with detrimental side effects and carry risks that far exceed those of HRT. (I ain’t sayin’ there’s a conspiracy to sell more drugs, but HRT is cheap, generic and effective, so it’s not profitable. Draw your own conclusion.)

Certainly, there are individual risk factors everyone must consider when deciding if HRT is right for them.

But quality of life matters, too.

Is it worth the very, very small, highly unlikely risk to avoid the very REAL and proven risk of breaking a hip, joint pain, sleep disorders, heart disease, Alzheimer’s and a whole host of other issues that impact quality of life?

For me, the answer is a resounding, “YES.”

**This is not medical advice, and I am not a doctor. The information here is based on my personal experience and research.

If you’re like me, you probably remember being in late elementary school or early junior high and getting “the talk.” They separated the boys and girls and danced around sex education by covering the bare minimum: they named the parts and talked about periods, pregnancy and prevention.

It was awkward—in fact, almost intentionally so, probably to encourage abstinence. It made us feel embarrassed about our bodily functions, periods in particular. And we got the message loud and clear that this was not a subject to talk about openly. It was impolite. Taboo. Gross, even.

And for most of us, that was it. Other than some later conversations with my mom as a teenager, that was the end of my female health education. It ended at pregnancy, with a strong hint that it was to be avoided.

There was ZERO discussion about what happens after that. I had heard of menopause, but honestly? It seemed like a goal I couldn’t wait to achieve. Finally, no more monthly periods! SIGN ME UP. What’s not to love?

Good lord—I had no clue what I was in for.

Chances are, most of us didn’t. Women make up 51% of the population and 100% of us will go through menopause if we’re lucky to live long enough. Yet NO ONE talks about this, what it means or how it feels. The fact that we’re expected to live nearly half our lives in this deficient (and often miserable) state is just completely ignored.

That’s absurd. Let’s fix that right now with a basic Q&A:

What is menopause?

Technically, menopause is defined as the day that is one year after your last period. That’s it—it’s literally just one day. After that, you’re considered “post menopausal.”

The problem is, this is a completely manmade, made-up, arbitrary milestone. By the time you’re one year after your last period, your hormones (estradiol, progesterone and testosterone) have completely bottomed out. Menopause is a symptom of a low hormone state. It’s confirmation that your reproductive capability is over.

What is perimenopause?

Perimenopause is the time leading up to that magical Day of Menopause, when your hormones are beginning to decline. And for some of us, that time can be an eternity—up to 10 years or more. Perimenopause can start as early as your mid-30s, and often does start that early for women who’ve never had children or who smoke.

During this time, your hormones are declining, but it doesn’t happen at a nice, steady pace. Instead, it sputters like a car running out of gas—a surge one day, followed by a drop the next. It’s this roller coaster of hormones that causes symptoms for so many women. It’s like having PMS on steroids. Every day. For years.

What are some symptoms of perimenopause?

There are dozens—by some estimates, maybe a hundred. Our bodies are full of hormone receptors in virtually every organ. So when those hormones are depleted, it affects every system.

Hot flashes and night sweats are the most well-known. But it’s so much more than that. Perimenopause affects our skin and bones, our mood and cognition, our heart, our muscles, tendons and ligaments. Energy, sleep, digestion and metabolism are all impacted. Thyroid function often falters.

For many women, it’s an overall sense of not feeling like themselves anymore, even if they can’t quite put their finger on it. Something is just…off.

Will all women have symptoms?

That depends. Not everyone has hot flashes or night sweats, but that doesn’t mean they don’t have any symptoms. Many are living with symptoms every day that they have no idea are caused by hormone deficiency (like itchy ears, joint aches and pains, heart palpitations).

And even if you “feel fine,” many of the symptoms of menopause hormone deficiency go undetected until it’s too late. You can’t “feel” osteoporosis (brittle bones) developing. You don’t “feel” heart disease coming on. You don’t “feel” Alzheimer’s until the damage has already begun.

But all of these are known byproducts of a low hormonal state.

What is hormone replacement therapy (HRT)?

Hormone replacement therapy (HRT for short) is the practice of replacing the hormones women lose during the menopause transition. Much like a diabetic would use insulin replacement, HRT is the same thing—replacing what the body no longer makes on its own.

HRT comes in a variety of forms, but modern best practice involves replacing all three: estrogen, progesterone and testosterone. (Yes! Women make and need testosterone too!)

Is hormone replacement safe?

For the vast majority of women—yes. The Women’s Health Initiative (WHI) in 2002 created a false fear that HRT caused cancer, heart disease and blood clots. The results of the study were misleading, misinterpreted and reported inaccurately by the media.

But there was no walking it back, even when participating researchers objected. The damage had already been done.

Prior to the WHI study, roughly 40% of menopausal women were on HRT. After the WHI debacle, it dropped into the single digits. Women were terrified. And an entire generation of women (like my mother, and maybe yours, too) suffered as a result.

That’s why I’m here, writing about this stuff. To clear the air and do my part to help right that wrong so that our generation, and our daughters, won’t have to suffer.

**This is not medical advice, and I am not a doctor. The information here is based on my personal experience and research.

Hello friends! I’ve recently realized how I’ve failed to make use of this platform, so I aim to rectify that starting now. Over the past year, I’ve been pursuing a personal passion through my writing: education and advocacy for midlife women’s health awareness, particularly around menopause hormone replacement therapy. I’ve been writing on Substack since October, and I plan to syndicate those posts here.

This has both personal and professional motivations: I have benefited TREMENDOUSLY from hormone replacement (it’s no exaggeration to say it probably saved my 20+ year career as a professional writer), and I want everyone I know to realize the benefits of HRT, learn how we have been completely misled about the risks, and to feel good and age well with vitality! Professionally, I aim to expand my health writing repertoire, which has mostly focused on hi-tech, and potentially add women’s health coaching as a side business.

Now, without further ado, here’s the post that launched this endeavor, and I will add others in the coming weeks. I welcome your feedback!

Welcome to Gray Matter: Straight Talk about Midlife Women’s Health, Hormones and Vitality

I’m so thrilled you’re here! Thank you for joining me on this journey.

For those who don’t know me, I’ve spent my career translating complex technical concepts into clear, relatable stories, writing marketing and PR content for tech companies. Now I’m turning that skill set toward something far more personal: helping women make sense of midlife.

If you’ve ever felt confused, dismissed, or just plain fed up—Gray Matter is for you.

For too long, women have struggled to navigate the menopause transition in the dark. We’ve been gaslit by doctors who told us it’s all in our heads. Or “you’re too young for menopause.” Or it’s “just part of aging.”

Or my personal favorite: “There’s nothing we can do. We’re all miserable. Join the club!” (Yes, a provider actually said to me.)

I refuse to accept any of that BS, and you should, too.

Why ‘Gray Matter’?

The obvious play on words with my name was irresistible. But it’s also much deeper and more meaningful than that.

This space is dedicated to my mother, Claudia, who we lost to Alzheimer’s disease in January 2024 after nearly a decade of suffering. It was a cruel and dehumanizing decline for a woman who had always been sharp and had her shit together.

I’m convinced she suffered—and ultimately died—because of untreated hormonal decline due to menopause.

Like so many women of her generation, she lived with debilitating symptoms: chronic fatigue, poor sleep, and brain fog. She had fibromyalgia, which many researchers now believe is caused by low estrogen. The Alzheimer’s disease? Also tightly linked to estrogen decline. And she suffered a broken hip—again, directly caused by estrogen deficiency.

I wish I’d known then what I know now. Maybe I could have helped my mom before it was too late.

That’s what I aim to do here: provide information in a clear, no-nonsense way so that it might help someone—anyone—avoid that same fate. Gray Matter is a nod to the hormone/brain health connection, but that’s only part of the story. We’ll dig into it all.

How I got here

When my own body started revolting at around age 38—night sweats, anxiety, brain fog, exhaustion, unexplained weight gain—I had no idea it was perimenopause. I’d never discussed these issues with my mom before her cognitive ability declined to the point that it would have been impossible. Besides, “perimenopause” wasn’t even a thing back when she was my age.

So, I did what I do best: started researching. I dug into everything I could find—books, podcasts, blogs—covering everything from perimenopause, menopause and hormone replacement to nutrition and strength training. It turned out there WERE answers out there! You just had to dig for them.

I decided I wasn’t going to sit back and be quiet about this. So many women were in the same situation, and we needed to have this conversation—not in hushed voices, in private spaces, but publicly. Men needed to hear it, too!

I started writing about what I found. What began as a few Facebook posts generated a flood of “OMG, me too!” and “I thought it was just me!” messages.

That’s when I realized: so many women were struggling, but thought they were alone, or that this is just how it is—misery for the next 30 years. They didn’t have time or energy to research this stuff. They were already too busy juggling kids, careers, a household and tending to aging parents.

And I realized that’s exactly how I can help: By translating the science into something clear, credible and empowering.

Let’s Do This!

Gray Matter exists to bring clarity to the chaos of midlife women’s health. It’s about cutting through the noise and misinformation so women can have confident, informed conversations with their doctors instead of being dismissed or ignored.

I’m not a doctor. I’m a researcher, a writer, and a woman in the trenches. I’m still navigating this journey, and I don’t have all the answers. I hope we can find them, together.

Gray Matter is for my mom, who never had the answers she deserved. It’s for me, to provide an outlet for the information I so often want to word-vomit on everyone I know. And hopefully it’s for you, to help you feel seen, informed and a little less alone.

What to Expect

I aim to post at least twice a month, covering a wide range of topics. I’d love for you to share your own experiences or suggest topics you’d like me to tackle. Feel free to reach out with your ideas, questions, or stories. And if you find this worthwhile, please share it with anyone you think could benefit.

There’s still a massive void in honest, accessible information about women’s midlife health. By talking about these issues, we can bring them out of the gray and into the light.

Let’s get into it!

–Kara

**This is not medical advice, and I am not a doctor. The information here is based on my personal experience and research.